Suicide, with its related mortality and morbidity, represents a significant and preventable loss of human life. Existing research indicates that problematic alcohol and drug use are closely linked to both fatal and non-fatal suicide attempts. Given the strong association between substance use and suicide, an episode of substance use disorder (SUD) treatment provides a unique opportunity to decrease the likelihood of suicidal behaviors. However, there are no data on the effectiveness of specific interventions designed to decrease risk of suicidal thoughts and behaviors during an episode of SUD treatment in individuals at high risk for suicide. The proposed 2-year study will: (1) adapt and refine an existing cognitive-behavioral treatment (CBT) intervention designed to decrease suicidal thoughts and behaviors for use in SUD treatment settings;and (2) conduct a pilot randomized controlled trial with 50 patients in treatment for SUDs comparing the CBT intervention to usual care. This pilot randomized controlled trial will: (a) obtain information about the feasibility of these procedures in residential SUD treatment;(b) determine the distribution and variability of the primary (level of suicidal ideation) and secondary outcomes (suicide attempts, hopelessness, frequency of substance use) within intervention and control conditions. The strong existing data on the efficacy of the CBT intervention for use in other settings, combined with our prior knowledge of modifying interventions for individuals with SUDs, will allow us to progress quickly from the initial intervention modification process to conducting a pilot randomized controlled trial of this intervention. Patients will be screened at SUD treatment entry for a combination of a past suicide attempt and current suicidal ideation and will be randomized to CBT or control conditions. All participants in the pilot randomized controlled trial will be assessed at baseline, at the end of treatment, and at 3-month follow-up. From a public health perspective, SUD treatment programs contain large numbers of patients at high risk for future suicidal behaviors and therefore have the potential to play a central role in our nation's efforts to decrease suicide. The proposed project is the first step in our planned line of research intended to decrease the likelihood of suicidal thoughts and behaviors in individuals with SUDs and will provide all of the essential elements needed to design a large RCT in the future that is fully powered to test the impact of this intervention on post-treatment suicidal thoughts and behaviors in this high risk population. PUBLIC HEALTH RELEVANCE: The purpose of this project is to adapt an existing Cognitive-Behavioral Therapy (CBT) protocol to reduce suicidal thoughts and behaviors during an episode of substance use disorder treatment. The study will involve a pilot randomized controlled trial comparing this adapted CBT intervention to usual care in suicidal patients recruited from a residential substance use disorder treatment program in order to determine the distribution and variability of the primary and secondary outcomes within the intervention and control conditions.